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Last Updated: 9/3/2021

PACE of the Ozarks – Intake Form

Do you know someone struggling with physical, memory or health challenges? Are they "55 or older"?

If so, consider completing this Intake Form. This will allow us to contact them or their caregiver about PACE to learn more. If interested, we can start the process to assess eligibility for PACE - Program of All-Inclusive Care for the Elderly.

*Asterisk indicates required fields

Referral Information:

Has the person or family been informed of this referral:*

YesNo

Name of Potential Participant:

First Name:*

Last Name:*

Date of Birth (must be 55 or older for PACE):*

Sex:*

MaleFemale

Phone Number:*

Address Line 1:*

Address Line 2:

City:*

State:*

Zip:*

Lives In:

Benton CountyMadison CountyWashington County

Current Living Situation:*

Alone HomeAlone ApartmentLives with Family/FriendOther

Other:

Insurance:

MedicaidMedicareOther

Other:

Current Primary Care Physician:

Name of Caregiver / Support Person (if appropriate):

Caregiver / Support Person Relationship to Person Referred:

Caregiver / Support Persons Phone Number:

Current or Recent Challenges (please mark all that apply):*

Uses cane, walker, wheelchair, motorized scooterTransferring Challenges (bed, chair, walker)Needs Assistance with ToiletingCatheter or Ostomy CareDialysis
Confusion, Memory Challenges or DementiaDifficulty Managing Household TasksFall Risk or Recent FallsDaily Oxygen Use or Regular Shortness of BreathFrequent Emergency Visits (two or more in past two months)
Other

Other:

Additional Considerations:

Current Services Provided in the Home (please mark all that apply):

Home CarePT / OT / Speech-LangWound CareOther

Other:

Is there an open Adult Protective Services (APS) Report?

YesNoN/A

Referring Contact Name:

First Name:*

Last Name:*

Representing Organization / Title (if appropriate):

Referring Contact Phone Number:*

Relationship to Referred Individual:*

Additional Information

Upload Supporting Files

Upon submission, a member of our Intake Team will reach out to educate about PACE (within 2 – 4 business days). We will explore their needs and share information about the medical and supportive services available through PACE. After learning more, we will provide an option to start the intake process to determine eligibility and what PACE might look like based on their unique needs.

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